请用英文填写下列表格，我们的销售代表会在24小时内与您联系，为您提供服务。

Contact Name (required)

Contact Email (required)

Contact phone number (required)

Number of people to be insured (required)

Start date YYYY=Year, MM=Month, DD=Date (required)

End date YYYY=Year, MM=Month, DD=Date (required)

Arrival date YYYY=Year, MM=Month, DD=Date (required)

Country of origin (required)

Beneficiary name (required)

Sum insured
Deductible: Insurance benefit:

Passengers information:
First name:
Last name:
Gender: MF
Birthday:
Address in Canada:

Other passengers:
First name:
Last name:
Gender: MF
Birthday:
Address in Canada:

First name:
Last name:
Gender: MF
Birthday:
Address in Canada:

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